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PACIFIC HEALTH ALLIANCE
PRE-AUTHORIZATION FORM
IF MEDICAL RECORDS ARE NOT RECEIVED, IT WILL NOT BE REVIEWED. PLEASE
COMPLETE THE FORM IN ITS ENTIRETY. ALL TAX I.D./ CPT CODES MUST BE
COMPLETED.
#11
PHONE: (855) 754-7271 FAX: (650) 425-9468
Date of Request:
______________
Urgent (24 hours) Use only when following the standard time frame could seriously jeopardize the member’s life or health or ability to attain,
maintain, or regain maximum function.
Member Information
Health & Welfare Plan Name:
_________________________
______________________________
Patient Name:
___________________________
Member’s Plan Network:
DOB:
______________
_________________________
MID#
(Attach a copy of medical insurance card)
Address:
_____________________________________________
Phone# of Subscriber:
City:
______________________________
____________________________
Medicare Primary: Yes
No
State:
______
Zip:
Insurance: Yes
Other
________
No
Ordering Physician Information
_________________________________
Ordering Physician:
Address:
_______________________________________________
Tax ID # ____________________
YOUR NAME:
*Diagnosis :
________________
City:
Requesting Physician Signature:
CONTACT PHONE #:
(
Phone:
*CPT/HCPC Codes :
________________________
) ________________________
_______________
State:
_____________________
______
*ICD9:
Zip:
Date:
_________
______________
Is your provider contracted w/member’s plan:
YES NO ______________________________________________________
_______________________________________________________________
_______________
Fax:
___________________________________________
__________________________________________________
*Service Being Rendered:
____________________
_______________
*Quantity of visits if applicable:
_______________
_______________
_________
_____
______________
Authorization Request
SPECIALIST/ FACILITY:
______________________________________________________
Is this rendering provider contracting with member’s plan:
Address:
Phone:
NO ________________________________________________________
____________________________________
Expected Date of Service
Office
YES ______________
FAX:
TAX ID#:_______________________________________
City:
____________
State:
______
Zip:
__________
______________________________
Is this a retro authorization? If so please indicate date/range here: _____________________________
Inpatient Services
Outpatient Services
23 Hour Short Stay
PHA USE ONLY – DO NOT WRITE BELOW THIS LINE!!!!!!!
Approved # of Visits: __________________________________
Interqual Guidelines Met # ______________________________________
Authorization Number: ____________________________________ Valid From: _________________to ____________________Expirations Date
Denied Denial Reason: _________________________________________________________________________________________________________
Other ________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_________________________________
Medical Director Signature
_____________________________________
Case Manager/ Care Counselor Signature
______________________________
Date
***Authorization is subject to eligibility & benefits on date of service.***
To ensure proper payment for services rendered, please verify eligibility on date of service. If member is determined to be ineligible on date of
service, he/she may be responsible for payment of these services. Please contact the number listed on the patient card to verify eligibility.
Please send all claims to the address listed on the patient ID card_______________________________________